Ethische kwesties in de mondzorg voor kwetsbare ouderen

Voor kwetsbare ouderen is vaak intensieve preventieve en curatieve mondzorg nodig ten behoeve van de kwaliteit van leven. Door fysieke en cognitieve beperkingen van de oudere kunnen behandelingen niet altijd lege artis uitgevoerd worden, wat tot praktische problemen leidt. Hieraan gerelateerd doen zich morele vragen voor. Mondzorg voor kwetsbare ouderen kan, zelfs met beperkingen, bijdragen aan hoge kwaliteit van leven als deze ethische kwesties vaker expliciet daarin betrokken worden. Daarmee zal ook de morele druk van ethische kwesties op de zorgverlener worden verlicht. Het gaat veelal om ‘alledaagse’ ethische kwesties, waarvoor de betrokkenen met elkaar oplossingen kunnen vinden in open overleg in een zorgethische benadering. Dat laatste betekent gerichtheid op ‘de goede dingen goed doen’ met inbegrip van alle relevante aspecten van de persoon en de omgeving. Voorwaarden zijn onder andere inbedding van de mondzorg in de zorg voor ouderen en voor zorgverleners betrokkenheid bij de oudere en kennis en vaardigheden om te reflecteren

The role of school-based dental programme on dental caries experience in Yogyakarta Province, Indonesia

Objectives. To assess the effectiveness of a school-based dental programme (SBDP) in controlling caries by measuring the relationship between the SBDP performance and caries experience in children aged 12 in Yogyakarta Province, Indonesia, by taking into account influencing factors. Methods. A cross-sectional survey was undertaken of 1906 children participating in SBDPs. Four SBDPs were chosen by good and poor performances in urban and rural areas. Caries was assessed using WHO criteria whereas behaviour and socio-demographic factors were collected using a questionnaire administered to the children. Results. The decayed, missed, and filled teeth (DMFT) of children in good SBDPs (2.8 +/- 2.4) was lower than that of the counterparts (3.8 +/- 3.4). From path analysis using a structural equation model (SEM), place of residence (OR = 4.0) was shown to have a strongest direct relationship to caries experience, whereas SBDP performance showed no direct relationship. At the same time, SBDP performance was significantly related to frequencies of dental visits (OR = 0.3), sugar consumption (OR = 0.8), and tooth brushing (OR = 3.2), which in turn are interrelated with place of residence, gender, and mother's education. Conclusions. The study suggests that the differences in DMFT of children in good and poor performance SBDPs were caused by relation to social factors rather than by relation to oral health service activities

Resistance to different classes of drugs is associated with impaired apoptosis in childhood acute lymphoblastic leukemia

Resistance of leukemic cells to chemotherapeutic agents is associated with an unfavorable outcome in pediatric acute lymphoblastic leukemia (ALL). To investigate the underlying mechanisms of cellular drug resistance, the activation of various apoptotic parameters in leukemic cells from 50 children with ALL was studied after in vitro exposure with 4 important drugs in ALL therapy (prednisolone, vincristine, l-asparaginase, and daunorubicin). Exposure to each drug resulted in early induction of phosphatidylserine (PS) externalization and mitochondrial transmembrane (Deltapsim) depolarization followed by caspase-3 activation and poly(ADP-ribose) polymerase (PARP) inactivation in the majority of patients. For all 4 drugs, a significant inverse correlation was found between cellular drug resistance and (1) the percentage of cells with PS externalization (<.001 < P <.008) and (2) the percentage of cells with Deltapsim depolarization (.002 < P <.02). However, the percentage of cells with caspase-3 activation and the percentage of cells with PARP inactivation showed a significant inverse correlation with cellular resistance for prednisolone (P =.001; P =.001) and l-asparaginase (P =.01; P =.001) only. This suggests that caspase-3 activation and PARP inactivation are not essential for vincristine- and daunorubicin-induced apoptosis. In conclusion, resistance to 4 unrelated drugs is associated with defect(s) upstream or at the level of PS externalization and Deltapsim depolarization. This leads to decreased activation of apoptotic parameters in resistant cases of pediatric AL

Decreased PARP and procaspase-2 protein levels are associated with cellular drug resistance in childhood acute lymphoblastic leukemia

Drug resistance in childhood acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) is associated with impaired ability to induce apoptosis. To elucidate causes of apoptotic defects, we studied the protein expression of Apaf-1, procaspases-2, -3, -6, -7, -8, -10, and poly(adenosine diphosphate [ADP]-ribose) polymerase (PARP) in cells from children with acute lymphoblastic leukemia (ALL; n = 43) and acute myeloid leukemia (AML; n = 10). PARP expression was present in all B-lineage samples, but absent in 4 of 15 T-lineage ALL samples and 3 of 10 AML cases, which was not caused by genomic deletions. PARP expression was a median 7-fold lower in T-lineage ALL (P < .001) and 10-fold lower in AML (P < .001) compared with B-lineage ALL. PARP expression was 4-fold lower in prednisolone, vincristine and L-asparaginase (PVA)-resistant compared with PVA-sensitive ALL patients (P < .001). Procaspase-2 expression was 3-fold lower in T-lineage ALL (P = .022) and AML (P = .014) compared with B-lineage ALL. In addition, procaspase-2 expression was 2-fold lower in PVA-resistant compared to PVA-sensitive ALL patients (P = .042). No relation between apoptotic protease-activating factor 1 (Apaf-1), procaspases-3, -6, -7, -8, -10, and drug resistance was found. In conclusion, low baseline expression of PARP and procaspase-2 is related to cellular drug resistance in childhood acute lymphoblastic leukemia

Asparagine synthetase expression is linked with L-asparaginase resistance in TEL-AML1-negative but not TEL-AML1-positive pediatric acute lymphoblastic leukemia

Resistance to L-asparaginase in leukemic cells may be caused by an elevated cellular expression of asparagine synthetase (AS). Previously, we reported that high AS expression did not correlate to L-asparaginase resistance in TEL-AML1-positive B-lineage acute lymphoblastic leukemia (ALL). In the present study we confirmed this finding in TEL-AML1-positive patients (n = 28) using microarrays. In contrast, 35 L-asparaginase-resistant TEL-AML1-negative B-lineage ALL patients had a significant 3.5-fold higher AS expression than 43 sensitive patients (P < .001). Using real-time quantitative polymerase chain reaction (RTQ-PCR), this finding was confirmed in an independent group of 39 TEL-AML1-negative B-lineage ALL patients (P = .03). High expression of AS was associated with poor prognosis (4-year probability of disease-free survival [pDFS] 58% +/- 11%) compared with low expression (4-year pDFS 83% +/- 7%; P = .009). We conclude that resistance to l-asparaginase and relapse risk are associated with high expression of AS in TEL-AML1-negative but not TEL-AML1-positive B-lineage ALL

Farm-like indoor microbiota in non-farm homes protects children from asthma development

Asthma prevalence has increased in epidemic proportions with urbanization, but growing up on traditional farms offers protection even today(1). The asthma-protective effect of farms appears to be associated with rich home dust microbiota(2,3), which could be used to model a health-promoting indoor microbiome. Here we show by modeling differences in house dust microbiota composition between farm and non-farm homes of Finnish birth cohorts(4) that in children who grow up in non-farm homes, asthma risk decreases as the similarity of their home bacterial microbiota composition to that of farm homes increases. The protective microbiota had a low abundance of Streptococcaceae relative to outdoor-associated bacterial taxa. The protective effect was independent of richness and total bacterial load and was associated with reduced proinflammatory cytokine responses against bacterial cell wall components ex vivo. We were able to reproduce these findings in a study among rural German children(2) and showed that children living in German non-farm homes with an indoor microbiota more similar to Finnish farm homes have decreased asthma risk. The indoor dust microbiota composition appears to be a definable, reproducible predictor of asthma risk and a potential modifiable target for asthma prevention.Peer reviewe

Differences in total tooth extraction between an urban and a rural area in the Netherlands

Differences in total tooth loss between an urban and a rural area (dentist‐patient ratio 1:2500 and 1:5700 respectively) have been studied. Patients who participated in this study were those who received total tooth extraction during the calender yr 1982 (urban area) and 1983 (rural area). The overall dentist response was 90%, the combined patient response was 75%. During the year, in the urban area 137 cases of total tooth extraction were recorded; in the rural area this was 237. This frequency is equivalent to 109 and 226 total tooth extractions per 100 000 inhabitants, respectively. The age and sex distribution of the urban and rural population could not account for this difference. The rural population had a lower educational level and more people insured in a State Health Scheme, which is related to income. The frequency of symptomatic attenders was highest in the rural area among those who were insured in a State Health Scheme. It is concluded that differences in numbers of total extractions between the rural and urban areas cannot be explained entirely by differences in population characteristic

Impact of school-based dental program performance on the oral health-related quality of life in children

Objective: To assess the association between the performance of school-based dental programs (SBDPs) and oral health-related quality of life (OHRQoL) in school children, in the province of Yogyakarta, Indonesia, taking into account untreated caries and sociodemographic factors. Methods: A cross-sectional survey was administered with 1906 children aged 12 and participating in SBDPs. Four SBDPs were chosen to represent good and poor performance in urban and rural areas. Caries was assessed using World Health Organization (WHO) criteria, whereas the children were interviewed for the OHRQoL and sociodemographic data. The OHRQoL was assessed using the Condition-Specific Child-Oral Impact on Daily Performances (CS Child-OIDP) index related to dental caries. Results: The mean CS Child-OIDP score was 1.63 (SD +/- 3.20) for good performance SBDP and 6.89 (SD +/- 8.85) for poor performance SBDP. Analysis by negative binomial regression showed that being served by a poorly performing SBDP (RR = 4.45, 95% CI = 3.87-5.13), and to some extent living in a rural area and being a girl, were significantly associated with a greater risk of having a lower quality of life than were the counterparts. Untreated caries did not show an association with OHRQoL. Conclusion: There are substantial indications that SBDP performance is related to children's OHRQoL